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Please fill out all the required fields on this form.  Once the form is signed you will be sent an email containg this form.  

You may print this form and bring it to the OHVA outing.  Or upon check in, you may show your completion email from a mobile device to verify you have completed this.  This waiver is valid for all OHVA events/outings during the 19-20 school year.  

First Participants Name

First Name*

Middle Name

Last Name*

Phone*
First Participants Date of Birth*
First Participants Signature*
Second Participants Name

First Name*

Middle Name

Last Name*
Second Participants Date of Birth*
Third Participants Name

First Name*

Middle Name

Last Name*
Third Participants Date of Birth*
Fourth Participants Name

First Name*

Middle Name

Last Name*
Fourth Participants Date of Birth*
Fifth Participants Name

First Name*

Middle Name

Last Name*
Fifth Participants Date of Birth*
Sixth Participants Name

First Name*

Middle Name

Last Name*
Sixth Participants Date of Birth*
Seventh Participants Name

First Name*

Middle Name

Last Name*
Seventh Participants Date of Birth*
Eighth Participants Name

First Name*

Middle Name

Last Name*
Eighth Participants Date of Birth*
Ninth Participants Name

First Name*

Middle Name

Last Name*
Ninth Participants Date of Birth*
Tenth Participants Name

First Name*

Middle Name

Last Name*
Tenth Participants Date of Birth*
Parent or Learning Coach Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Student ID #:

Student 1 *

Student 2

Student 3

Student 4

Student 5
Name of Outing

Name of Outing *

Date of Outing *
In case of an emergency, and I am not available, the OHVA staff has my permission to secure medical attention for my child.
Yes
No
Please note any special medical conditions: drug allergies, diabetes, food allergies, etc
I give permission for my child to be photographed while on the outing, and for photos to be used in school newsletters or publications.
Yes
No
If injuries are incurred by my student or myself, I will not hold Ohio Virtual Academy, school staff or volunteers liable, and understand it is my responsibility to supervise my child(ren) during a school event.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Learning Coach Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Learning Coach Date of Birth*
Parent or Learning Coach Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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